Basic Information
| Provider Information | |||||||||
| NPI: | 1699042903 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITA | ||||||||
| FirstName: | ERVIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 GRANDE BLVD | ||||||||
| Address2: | |||||||||
| City: | DELRAN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080751376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2679741889 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 HAMILTON AVE | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086291915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095995000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2011 | ||||||||
| LastUpdateDate: | 12/02/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | 26NR12158700 | NJ | Y | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
No ID Information.